Guidelines for Malaria

Transcription

2012
Guidelines for Malaria
www.nt.gov.au/health
Prepared by the Centre for Disease Control, Darwin and Infectious Diseases Unit, Royal Darwin
Hospital.
1st Edition
2nd Edition
3rd Edition
4th Edition
5th Edition
6th Edition
June 1991
March 1994
January 1997
June 2004
April 2007
September 2012
The Malaria Treatment Guidelines pages 15-20 are reproduced with permission from the Antibiotic Expert
Group - Malaria. In: Therapeutic Guidelines: Antibiotic. Version 14. Melbourne: Therapeutic Guidelines
Limited; 2010. pp.163–70.
For assistance with possible malaria cases contact the following urgently:
Working hours Infectious Diseases Registrar
Royal Darwin Hospital
Ph: 8922 8888
After hours
Infectious Diseases Physician on call
Royal Darwin Hospital
Ph: 8922 8888
Centre for Disease Control
Department of Health, Northern Territory 2012
This publication is copyright. The information in this report may be freely copied and distributed for
non-profit purposes such as study, research, health service management and public information
subject to the inclusion of an acknowledgement of the source. Reproduction for other purposes
requires the written permission of the Chief Executive of the Department of Health, Northern Territory.
This is an ePublication only available from Centre for Disease Control, publications web page:
www.nt.gov.au/health/cdc
General enquiries are welcome and should be directed to:
Senior Branch Manager
Department of Health
PO Box 40596
Casuarina NT 0811
Phone: 08 8922 8089
Facsimile: 08 8922 8310
For further information contact your regional Centre for Disease Control
Darwin:
Disease Control
ph 8922 8044
Katherine:
Disease Control
ph 8973 9049
East Arnhem:
Disease Control
ph 8987 0359
Tennant Creek:
Disease Control
ph 8962 4259
Contents
APPENDIX 2. Malaria Surveillance Case Questionnaire...........................................................................20
Introduction....................................................................................................................................................1
APPENDIX 3. Use of IV artesunate for severe and complicated malaria................................................23
Risks of re-establishing endemic malaria in the Northern Territory........................................................1
APPENDIX 4. Primaquine: patient information..........................................................................................25
Prevention and prophylaxis.........................................................................................................................2
APPENDIX 5. Guidelines for assessing unauthorised Indonesian fisherpersons for malaria.............26
Diagnosis.......................................................................................................................................................2
APPENDIX 6. Advise to parents of students arriving in the NT from malaria endemic areas .............28
NT Case definition ........................................................................................................................................3
APPENDIX 7. Medical Entomology investigation......................................................................................31
Initial management of malaria......................................................................................................................4
APPENDIX 8. Malaria factsheet...................................................................................................................32
Ward monitoring and discharge plan .........................................................................................................5
APPENDIX 9. Malaria factsheet (Indonesian)............................................................................................34
Management of malaria................................................................................................................................6
Principles of management ..............................................................................................................................6
Place of treatment...........................................................................................................................................6
Initial management..........................................................................................................................................7
Indications for intensive care unit or high dependency unit admission for parenteral therapy........................7
Discharge to HITH...........................................................................................................................................8
Referral to and management of patients with malaria via Hospital in the Home (HITH).................................8
Eradication treatment for P. vivax and P. ovale dormant stages......................................................................9
Follow-up.........................................................................................................................................................9
Public health response.................................................................................................................................10
Background.....................................................................................................................................................10
Screening of high risk groups..........................................................................................................................10
Refugee migrant screening.............................................................................................................................10
Management of co-travellers...........................................................................................................................10
Role of CDC Malaria Surveillance Officer (MSO)............................................................................................11
Medical Entomology .......................................................................................................................................12
Malaria public health response....................................................................................................................13
APPENDIX 1...................................................................................................................................................14
Therapeutic guidelines: antibiotic. Malaria 2010........................................................................................14
Treatment.......................................................................................................................................................14
Uncomplicated Plasmodium falciparum malaria.............................................................................................14
Severe malaria................................................................................................................................................15
Other forms of malaria.....................................................................................................................................16
Prophylaxis....................................................................................................................................................17
Vector avoidance.............................................................................................................................................18
Chemoprophylaxis...........................................................................................................................................18
Areas with chloroquine-susceptible malaria....................................................................................................18
Areas with chloroquine-resistant malaria........................................................................................................19
Areas with mefloquine-resistant malaria.........................................................................................................19
Stand-by emergency treatment....................................................................................................................19
Malaria Guidelines for Health Professionals in the Northern Territory
This document outlines some selected and unique aspects of malaria surveillance and control in the
Northern Territory (NT). It describes the intensive measures that are essential if we are to prevent the
re-establishment of malaria in the NT.
The malaria control program in the NT is a responsibility shared among general practitioners,
hospitals, laboratories, medical entomology, community care/health centres, disease control units
and the general community.
Introduction
The NT has a comprehensive malaria surveillance and control program that includes:
a. Early detection and hospitalisation of cases;
b. Correct treatment of cases;
c. Follow up of cases after discharge from hospital;
d. Centre for Disease Control (CDC) assessment of all cases to establish appropriate entomological
investigation;
e. Advice on prophylaxis for travel overseas via e.g. Health Services Australia (HSA) Travel
Doctor and certain General Practitioners; and
f. Screening and treatment/cure for high risk groups, for example refugees, migrants, illegal
fisherpersons and co-travellers of cases who have malaria.
Malaria is caused by the blood parasite Plasmodium. There are 5 species that infect humans:
P. falciparum, P. vivax, P. ovale, P. malariae and in South East Asia only, P. knowlesi.
The parasite is transmitted to humans by the bite of an infected mosquito. The female mosquitoes of
the genus Anopheles are the only mosquitoes that can transmit malaria. The malarious areas across
the world include:
•• Africa, Middle East, Asia, China, South East Asia including Indonesia, East Timor, Papua New
Guinea, the Western Pacific Islands, and Central and South America.
Risks of re-establishing endemic malaria in the Northern Territory
The World Health Organization (WHO) certified the eradication of malaria from Australia in 1981, but
Northern Australia still remains susceptible to the re-establishment of the disease.
The receptive area is considered to be north of the 19th parallel which is a line just north of Townsville
in Queensland and just south of Broome in Western Australia. The area includes the northern third of
the NT, (north of Tennant Creek) and is considered at risk because of:
a. A history of endemic malaria until 1962;
b. Widespread breeding of the Anopheles mosquito;
c. Breeding of Anopheles mosquitoes in urban areas; and
d. Regular tourist traffic from malarious countries, particularly Indonesia, East Timor and Papua
New Guinea.
1
DEPARTMENT OF HEALTH
The average number of imported cases of malaria to the Northern Territory each year over the last 10
years is 40 (range 15–71). The Northern Territory has 20.8 notifications per 100,000 population which
is the highest per capita notification rate when compared to other Australian jurisdictions.
The re-establishment of malaria in the NT could result in extensive morbidity and mortality in our
population. Every effort is therefore made to keep the NT malaria free and to maintain Australia’s
malaria free status.
Prevention and prophylaxis
With Territorians travelling more to endemic malaria areas, including Aboriginal Australians who return
to highly malaria-receptive remote areas of the Top End, health professionals need to understand
and give expert and current travel medicine advice. Such expert advice on malaria prevention and
prophylaxis can be gained through travel medicine clinics, the WHO (www.who.int/ith/en) or CDC
Atlanta Guidelines (http://www.cdc.gov/travel/). Advice is also included in Therapeutic guidelines;
antibiotic. Version 14, 2010 (see Appendix 1).
NT Case definition
Malaria
Reporting
Reporting is made to the Northern Territory Notifiable Diseases System (NTNDS). Confirmed
cases are sent from the NTNDS to the National Notifiable Diseases Surveillance System (NNDSS).
Probable cases are reported to the NTNDS only.
Confirmed case
A confirmed case requires laboratory definitive evidence.
Probable case
A probable case requires laboratory suggestive evidence.
Diagnosis
Malaria is diagnosed by detection of the parasite through microscopy of thick and thin blood films.
As identification of malaria parasites is not a common laboratory event in Australia, the Haematology
Laboratory at the Royal Darwin Hospital (RDH) and the Institute of Medical and Veterinary Science
(IMVS) provide a service for confirmation of malarial parasites and species identification for all
public and private laboratories servicing the NT. Malaria microscopy is the ‘gold standard’ for the
current NT confirmed case definition and remains mandatory for the diagnosis of malaria and species
identification. Malaria antigen testing shows the presence of plasmodial antigens and can be useful
in supporting microscopy for diagnosis. However a negative antigen test does not exclude malaria
infection (eg. low parasite numbers) and an antigen test can remain positive for up to 4 weeks after
appropriate treatment. Polymerase chain reaction (PCR) is not routine and is not the gold standard.
Malaria is a legislated notifiable disease in the NT.
Laboratory definitive evidence
1. Detection and specific identification of malaria parasites by microscopy on blood films with
confirmation of species in a laboratory with appropriate expertise
OR
2. Detection of Plasmodium species by nucleic acid testing.
Laboratory suggestive evidence
The detection of Plasmodium antigen in blood in the absence of recent appropriate treatment (and
the case is not a confirmed case).
Any traveller who has returned from a malarious region in the past 2 years and who has a fever or
history of fever should undergo testing for malaria parasites and antigen. The decision to have blood
films taken should not be influenced by compliance with prophylaxis regimens as it is possible to be
infected with malarial parasites and develop malaria even when anti-malarials have been correctly
taken.
The absence of parasites on a blood slide does not exclude malaria, particularly if a person has
recently taken anti-malarials or antibiotics. If negative, a blood slide should be repeated 6-24 hours
later and at least daily thereafter if fever persists.
2
3
Ward monitoring and discharge plan
Initial management of malaria
•• Daily parasite count until negative
•• Daily blood glucose and full blood count
•• Closely monitored BP and urine output
Case must be discussed with Infectious Diseases Physician
(all hours)
Treat as complicated malaria if
one or more of the following:
•• Unable to tolerate oral
medication
•• Parasitaemia >2%
•• Any signs of severe malaria:
⇒⇒altered mental state
⇒⇒jaundice
⇒⇒renal impairment
⇒⇒oliguria
⇒⇒unable to sit unaided
⇒⇒respiratory distress
⇒⇒severe anaemia
⇒⇒hypoglycaemia
⇒⇒acidosis
Treatment
Adults (excluding pregnant
women in 1st trimester) and
children >5kg
- 1st line: artemether/lumefantrine
(Riamet)*
Pregnant women (1st trimester)
and children <5kg
- quinine sulfate† and clindamycin
•• All P. falciparum
•• All P. knowlesi‡
•• All P. malariae
•• P. vivax
•• P. ovale
(laboratory confirmation that
there is no co-infection with
P. falciparum)
Criteria for hospital admission
•• Parasitaemia >1%?
•• Child <12 months old?
•• Sigificant co-morbidity? eg. ischaemic
heart disease
••Pregnant (urine test for all women of child
bearing age)?
••Unable to tolerate oral medication
••Accommodation requirements are not
met (see HITH p 6, 7)
Admit to HDU/ICU if
severe malaria
- 1st Line - IV Artesunate
(Appendix 2)
- 2nd line - IV Quinine
(See Appendix 1/
protocol in ICU)
YES to ANY
Admit to ward
Adults under Infectious Diseases team
Children (Paediatric team)
see ward monitoring p 5
NO to ALL
Admit to HITH§
see ward monitoring p 5
* Give with a small glass of milk or a soft biscuit as fat increases the absorption.
†
‡
§
If unable to tolerate quinine discuss with Infectious Diseases Physician.
P. knowlesi malaria is indestinguishable from P. malariae on microscopy. All P. malariae cases with a history of travel to
South East Asia should be treated as P. knowlesi.
Patients can not be discharged to Hospital in the Home (HITH) after 9pm and should be admitted at least overnight.
4
Ward/ED discharge plan
P. vivax
P. ovale
Ward discharge plan
P. falciparum
P. malariae
P. knowlesi
Uncomplicated
Complicated
i. Ongoing oral treatment being
tolerated
ii. Clinically improving
iii. Parasitaemia falling
Treatment being tolerated
G6PD activity
G6PD activity
Normal
Parasitaemia falling
Deficient
Stat dose of primaquine
on full stomach (45mg for adults)
(0.7mg/kg for children (max 45mg))
to sterilise gametocytes
Deficient
Seek
specialist
advice
Normal
Transfer to HITH
Complete a total of 3 days malaria
treatment observed twice a day
by HITH. Daily blood films until no
parasites seen
Transfer to HITH
Complete a total of 3 days malaria
treatment observed twice a day
by HITH. Daily blood films until no
parasites seen
14-day primaquine therapy
commenced to eradicate
hypnozoites
(to be taken on a full
stomach)
Review and repeat malaria film
in 1 week in Infectious Diseases/
Paediatric outpatient clinic, Refugee
Clinic* or in Detention Centre
In very selected cases (eg. residents from endemic
countries), Infectious Diseases Physician to consider
14-day primaquine therapy (if G6PD activity is normal)
in P. falciparum cases in view of possible co-infection
with P. ovale and or P. vivax (primaquine to be taken on
a full stomach).
Review with blood film
1 week after discharge
in Infectious Diseases/
Paediatric outpatient clinic
* Refugee Clinic is offered by Vanderlin Drive surgery, transport for refugees is available through Melaleuca Refugee
Centre
5
Management of malaria
f.
Principles of management
g.
Because of the public health ramifications of malaria and the complexity of the parasite’s life cycle, the
principles of treatment are to cure the individual and prevent relapses but also include reducing and
eliminating transmission. The aims of treatment are as follows:
a. Eradication of the malaria parasites with specific antimalarial medication;
b. Sterilisation of the sexual forms (gametocytes) with a specific gametocidal drug (primaquine)
to prevent transmission of the parasite to mosquitoes;
c. Eradication of the dormant liver forms (hypnozoites) of P. vivax and P. ovale with a 2-week
course of primaquine; and
d. Prevention of transmission to local mosquitoes by physically separating the parasitised patient
from the mosquito environment until no longer able to transmit the parasite.
h.
A detailed history must be obtained from every patient (see Appendix 2) including an itinerary of
overseas travel and movement following their return to Australia. The history will help in assessing the
risk of parasite drug resistance, inform further entomological assessment and allow for identification
of co-travellers.
Place of treatment
i.
j.
k.
l.
Where the patient is gametocyte positive that the first dose of artemether/lumefantrine has
been given;
The patient is affected mildly by malaria ie. tolerating oral fluids and diet and has tolerated the
first treatment dose;
The patient agrees to remain indoors in screened or air conditioned accommodation between
dusk and dawn until artemether/lumefantrine therapy is completed;
Another household member has a phone and is able to use it if the patient becomes unwell or
there is an emergency*;
The patient speaks a language for which a telephone interpreter or friend/family member can
interpret eg. Swahili, French, Dinka, Arabic, Kirundi. If it is a rare language and no lingua
franca can be found, the patient will have to be admitted;
The patient is notified to CDC so that CDC officers can ascertain that patients treated as
HITH/outpatients do not pose a public health risk. A phone message may be left with CDC
after hours; and
The case has been discussed with an Infectious Diseases (ID) Physician at RDH (available
24 hours per day) to check:
•• The above points a to l
•• Clinical condition
•• Follow-up arrangements
•• Spleen size and offer advice about sporting restrictions.
Initial management
Hospital
All cases of P. falciparum, P. malariae and P. knowlesi malaria and any malaria cases where the
species cannot be confirmed within 24 hours require assessment in hospital.
•• This is the preferred practice in the NT to prevent life threatening complications of P. falciparum.
•• It is also important to avoid any risk of transmission of the parasite to the mosquito vectors that
are present in the Top End of the NT.
•• Patients are initially nursed in an air-conditioned ward, and must not leave the ward between
6pm and 8am.
•• Asymptomatic patients with low parasitaemia eg. refugees may be treated through Hospital in
the Home (HITH) after review by the Infectious Diseases registrar or consultant at RDH.
Hospital in the home (HITH)
Confirmed P. vivax, or P. ovale can be treated by HITH provided:
a. Parasitaemia is <1%;
b. The child is >12 months of age;
c. There are no significant co-morbidities eg. ischaemic heart disease;
d. Pregnancy is excluded;
e. There is no evidence of co-infection with P. falciparum malaria. This requires blood microscopy
confirmation of species by an accredited specialist microscopist;
6
Uncomplicated malaria should be treated as per protocols outlined in Therapeutic guidelines: antibiotic.
Version 14, 2010 (see Appendix 1). Because of difficulties accessing chloroquine, artemether/
lumefantrine is the preferred oral treatment for P. vivax from any malaria region.
Indications for intensive care unit or high dependency unit admission for parenteral
therapy
••
••
••
Any degree of altered consciousness, jaundice, oliguria, severe anaemia or hypoglycaemia
A parasite count above 100,000/mm3 (>2% of red blood cells parasitised)
The patient is vomiting or clinically acidotic.
Severe falciparum and knowlesi malaria can be fatal, particularly if the diagnosis and treatment is
delayed. The World Health Organization has a handbook on the management of severe malaria
(http://www.who.int/malaria/en/). Intensive care units have protocols for the management of severe
malaria.
First line parenteral therapy of severe falciparum malaria is artesunate (see Appendix 3).
*Please note: There is a HITH nurse on call 24hours (they only speak English).
Unless the patient or a household member speaks English, there should be another contact person (Melaleuca Refugee
Centre or friend/neighbour) who is available to immediately attend the house if called.
7
Discharge to HITH
d.
Patients with P. falciparum, P. malariae, and P. knowlesi can be discharged to HITH when:
1. The oral course of anti-malarial medication is being tolerated
AND
2. They are clinically improving
AND
3. Parasitaemia is falling
AND
4. For cases of P. falciparum, P. malariae and P. knowlesi a stat* gametocidal dose of primaquine
(45mg for adults / 0.75mg/kg for children) is given at discharge if G6PD activity is normal.
e.
The discharge algorithm is on p 5.
Referral to and management of patients with malaria via Hospital in the Home (HITH)
See flow chart Ward monitoring and discharge plan p 5.
In working hours
a. Refer to the Infectious Diseases/HITH registrar ASAP.
b. ID/HITH registrar, along with a HITH nurse, will assess the patient’s suitability for discharge
home (see ward monitoring and discharge plan p 5).
c. The first dose of artemether/lumefantrine [and for P. falciparum the stat dose of primaquine
(45mg for an adult who is not G6PD deficient)], should be given and observed prior to transfer
to HITH. The patient should be observed for an hour following this to ensure no vomiting. Give
with a small glass of milk or a soft biscuit as fat increases the absorption.
d. If the patient is ≤12 years of age, the paediatrician on call should be involved.
Out of working hours (after 9pm)
a. Patients can not be discharged to HITH after 9pm and should be admitted to hospital at least
overnight.
b. The next morning the HITH nurses/registrar can assess the patient and discharge to HITH
if appropriate. HITH nurses are available on weekends during working hours and must be
consulted if a discharge is planned on a weekend, as must be the ID consultant on call.
Management at HITH
a.
b.
c.
If the patient or a household member speaks no English, use the Telephone Interpreter
Service during visits [TIS 131450, Client number (your allocated number)].
Once treatment has been completed for a refugee, liaise with the Refugee Clinic Vanderlin
Drive Surgery (8945 5888) regarding follow-up. In most cases this will involve blood films
and FBC and clinical review at day 28 post-treatment.
Eradication treatment for P. vivax and P. ovale dormant stages
The aim of this treatment is to eradicate the hidden liver phase of P. vivax or P. ovale (hypnozoites)
which can lead to relapses of malaria after months or years.
It is given for:
•• Those diagnosed with P. vivax or P. ovale infection who have a normal G6PD result;
•• Those with P. falciparum who are at high risk of co-infection with P. vivax hypnozoites;
Although 14 day primaquine eradication treatment is not routinely offered to all people arriving
from malarious areas due to possible co-infection with P. vivax it is strongly recommended for:
a. Migrants and refugees from regions with high endemicity for vivax malaria (eg. PNG,
Solomon Islands, eastern Indonesia). This does not include refugees from Africa.
b. Expatriate workers resident for prolonged periods in regions with high endemicity for vivax
malaria.
Radical treatment consists of treatment with primaquine for 14 days (refer to Therapeutic guidelines:
antibiotic. Version 14, 2010). Note the need for the higher dose of 0.5mg/kg/day dose in P. vivax
infections.
Blood tests to exclude parasitaemia and G6PD deficiency should be performed before starting
eradication treatment (1-2mL blood in an EDTA tube). If parasitaemia is present the person must be
treated accordingly. If the person has G6PD deficiency primaquine should be withheld and further
management should be discussed with an Infectious Diseases Physician.
Treatment must be reviewed both to ensure compliance and to assess any side effects (eg. haemolysis,
methaemoglobinaemia, nausea, vomiting, anorexia, dizziness, epigastric distress and abdominal
pains or cramps). Treatment must be taken with food to avoid gastrointestinal side effects.
Patients will be given an information sheet outlining the possible side effects from primaquine
(Appendix 4).
Follow-up
Give each artemether/lumefantrine dose BD at 0800 and 2000 with a small glass of milk or a
soft biscuit (directly observed therapy by HITH nurse) for a total of 6 doses (note the second
dose is to be given 8 hours after the initial dose).
Do daily malaria films until no parasites are seen.
There is no need to repeat malaria antigen test during treatment.
8
Patients should be reviewed with a blood film by the admitting Infectious Diseases/Paediatric team
7 days after treatment is commenced (including a check that primaquine (where necessary) is being
tolerated). The clinical review also notes the recovery of the patient and resolution of symptoms.
Patients should be advised that if there is recurrence of fever in the next 3 months they should seek
medical advice and repeat blood film.
9
Public health response
The pathology request form should include the term ‘co-traveller of malaria case’, the region most
likely that malaria was acquired and whether the co-traveller has any symptoms suggestive of malaria.
Co-travellers with positive smears are treated accordingly.
Background
The existence of competent malaria vectors such as Anopheles farauti s.l. in the Top End of the
Northern Territory means that each case of malaria diagnosed in the Top End is a potential risk for the
rest of the population. The NT has remained malaria free for many decades due to the strict isolation
of cases and prompt public health response by CDC and Medical Entomology.
Role of CDC Malaria Surveillance Officer (MSO)
1. Confirm that the case fulfils the case definition for a confirmed or probable case1 (see p 3).
2. Interview the case using the Malaria Surveillance Case Questionnaire (Appendix 2). This is
usually done face-to-face if the patient is in hospital but can be done by phone.
3. Make an assessment based on the onset of the illness and the travel history about the likely
source of infection. There is space in the enhanced data for 3 places of acquisition (‘country
of infection’), starting with the most likely. If the country is PNG, Indonesia or East Timor, the
region of infection should also be ascertained and documented.2
4. As part of the interview ascertain in detail the location of the case in the NT after they became
unwell (first fever). Include location of residence but also ask about any travel (including dates)
within the NT during that time. Document date of onset of fever.
5. If the case has been diagnosed by screening they may not have a history of fever, ask about
details of location in the NT since arrival.
6. Note whether gametocytes are present in the blood film.
7. Following collection of the enhanced data, inform Medical Entomology about the case. If there
are gametocytes present, Medical Entomology should be notified by phone and the completed
questionnaire forwarded.
8. Arrange for screening of co-travellers.3 This may be through General Practitioners but can be
arranged through CDC.
9. Core data entry from the Malaria Surveillance Case Questionnaire is entered into the NTNDS
by the MSO.
10. Two weeks after interview, check case record to ascertain the whether primaquine was used
(1 day or 14 day course). It might be necessary to contact the case for this information.
11. Enhanced data is then entered into the NTNDS by the MSO.
Malaria is scheduled as a notifiable disease under the Notifiable Disease Act and is urgently notifiable
by both doctors and laboratories. Notification of a case of malaria is usually received from laboratories
by phone but is sometimes received by fax. CDC may seek further information from clinicians. Once
diagnosed, the responsibility for initiating the public health response lies with the local CDC Malaria
Surveillance Officer (MSO) who then informs Medical Entomology, who may or may not instigate a
response in the community.
Screening of high risk groups
Protocols have been developed for screening for malaria parasites in high risk groups on entry to
the NT. Such groups include refugee migrants, illegal fisherpersons (see Appendix 5), students from
high-risk areas such as Papua New Guinea (see Appendix 6), West Papua and the Solomon Islands.
Over the last 10 years to 2010, 24% of all malaria infections in the NT were diagnosed by screening.
Contact NT CDC for further information on 8922 8804.
Refugee migrant screening
Due to the risk of asymptomatic carriage of malaria and potential local transmission, all newly arrived
refugees from Africa are screened preferably within 72 hours of arrival in Darwin.
CDC staff work in consultation with the Department of Immigration and Multicultural Affairs and
Melaleuca Refugee Centre to arrange transport and testing at Royal Darwin Hospital (weekdays). All
refugee migrants are tested with a thick and thin blood film and malaria antigen.
All positive malaria results (including positive antigen/negative blood film) are then phoned to the
Infectious Diseases Registrar on call who then contacts the Melaleuca Refugee Centre to arrange
immediate transport of the patient to the Emergency Department for assessment and treatment (see
flowsheet p 4).
See algorithm p 13.
Refugee migrants who have a positive antigen and negative film are assessed individually by the
Infectious Diseases Registrar and treated for malaria, even in the absence of parasites.
Management of co-travellers
All co-travellers of a malaria case with similar high risk malaria exposure should be tested for malaria
through the NT Centre for Disease Control (CDC). This is arranged by the MSO when the patient is
interviewed.
10
Note that there is an NT-only probable category for malaria
See the NTNDS data dictionary for lists of regions
3
The definition of co-traveller is not always straightforward but could be defined as anyone who was travelling with the
case at the likely time of acquisition and can be contacted.
1
2
11
Malaria public health response
Medical Entomology
Medical Entomology should be notified of all malaria cases and will assess the need for further
action. The Malaria Surveillance Officer from CDC will interview the patient as soon as possible
(within working hours), complete the NT Malaria Surveillance Case Questionnaire (Appendix 2), fax
it to Medical Entomology and file the original at CDC after notification. Of particular concern are
cases with gametocytes in their blood, as gametocytes are the form of malaria parasite infective to
mosquitoes (these patients should have received the first dose of artemether/lumefantrine or a stat
dose of primaquine as an inpatient or in the Emergency Department before transfer to HITH).
It is important to establish with the malaria case:
•• Where and when the patient was most likely infected;
•• Where they have been staying in the NT since they became symptomatic (including contact
details of the property owner);
•• How long they have been at that location; and
•• Whether they were bitten by mosquitoes between dusk and dawn at that location.
Medical Entomology investigation
Case of malaria
Laboratory notifies CDC and clinicians of
malaria, type and gametocyte status
•• CDC MSO* interviews
patient and completes
enhanced notification form
•• MSO organises screening
of co-travellers
Intervention
measures
Entomological
assessment
No action
The Medical Entomology investigation determines the risk of probable patient-vector contact and
therefore of possible transmission to mosquitoes.
The decision for further action is made on whether infective stages of malaria are present in the blood,
the location of the patient during first fever, the length of time since the first fever and the likelihood of
exposure to vector mosquitoes. The proximity of the patient’s residence and other places visited at night
to the nearest mosquito breeding sites are determined from maps. Previous mosquito trap catches
from these areas and the nearest routine mosquito monitoring site (if applicable) are assessed for the
potential presence of Anopheles species vector mosquitoes (see Medical Entomology investigation,
Appendix 7).
If the place of residence is a regional centre outside of Darwin, the relevant Environmental Health
Officer (EHO) is alerted to the need to set mosquito traps and the possible need to conduct an adult
control operation and to ensure equipment and staff availability.
After 2 weeks CDC MSO
phones case and interviews
to verify compliance with
primaquine treatment if
prescribed
Action that may be recommended if there is a possibility of local transmission may include:
•• Fogging operations around the immediate residential area or the nearest mosquito breeding
or harbouring area;
•• Limited surveillance for malaria in the neighbourhood;
•• A malaria warning pamphlet being distributed to nearby residents; and
•• Doctors and Community Care/Health Centres in the area being advised to be on alert for
patients with unexplained fevers or other suggestive symptoms.
Co-traveller
positive malaria slide
and/or antigen
Co-traveller malaria
screening
•• symptoms
•• malaria thick and thin film
•• malaria antigen
•• check for G6PD
Co-traveller
negative malaria slide
and antigen.
Records of all confirmed malaria case investigations are maintained at CDC, Darwin.
Discharge from followup from CDC after providing:
•• education on malaria (factsheet†)
•• future travel and malaria prophylaxis advice
•• advice on prevention of mosquito bites
* Malaria Surveillance Officer
†
12
Appendix 8 and 9
13
Co-traveller
Still has symptoms?
Discuss with
Infectious Diseases
Physician
APPENDIX 1
PLUS EITHER
doxycycline 100 mg (child more than 8 years: 2.5 mg/kg up to 100 mg) orally, 12-hourly for 7 days,
which need not commence on day 1
Therapeutic guidelines: antibiotic. Malaria 2010
Malaria must be considered in any patient who has visited a malarious area and presents with a febrile
illness. A blood sample collected into an EDTA tube should be sent to an appropriate laboratory for
examination, including thick and thin films.
A single negative blood film or negative antigen test does not exclude the diagnosis of malaria,
particularly if antimalarials or antibiotics have been taken recently. Certain antibiotics that are commonly
used by travellers, such as trimethoprim+sulfamethoxazole, tetracyclines and the fluoroquinolones,
have some antimalarial activity. This may modify or suppress malaria symptoms and make diagnosis
by blood film more difficult.
Of the 5 species that infect humans, Plasmodium falciparum is the most pathogenic and most resistant
to standard antimalarials.
OR (for pregnant females or children)
clindamycin 300 mg (child: 5 mg/kg up to 300 mg) orally, 8-hourly for 7 days.
Atovaquone+proguanil should not be used for treatment of malaria in patients who took these drugs
as prophylaxis.
Severe malaria
Urgent treatment of severe malaria is essential if the patient has any of the following:
••
••
••
Treatment
Uncomplicated Plasmodium falciparum malaria
Artemether+lumefantrine is the drug of first choice for the treatment of uncomplicated Plasmodium
falciparum malaria. Initial treatment in hospital is recommended. Use:
1. artemether+lumefantrine tablets 20+120 mg
adult and child more than 34 kg: 4 tablets (child 5 to 14 kg: 1 tablet; 15 to 24 kg: 2 tablets; 25 to 34
kg: 3 tablets) orally with fatty food or full-fat milk, at 0, 8, 24, 36, 48 and 60 hours, making a total
adult dose of 24 tablets in 6 doses
OR
2. atovaquone+proguanil tablets 250+100 mg (adult formulation)
adult and child more than 40 kg: 4 tablets (child 11 to 20 kg: 1 tablet; 21 to 30 kg: 2 tablets; 31 to 40
kg: 3 tablets) orally with fatty food or full-fat milk, daily for 3 days
OR THE COMBINATION OF
3. quinine sulfate 600 mg (adult less than 50 kg: 450 mg) (child: 10 mg/kg up to 600 mg) orally,
8-hourly for 7 days*
any degree of altered consciousness, jaundice, oliguria, severe anaemia or hypoglycaemia
a parasite count above 100 000/mm3 (greater than 2% of red blood cells parasitised)
the patient is vomiting or clinically acidotic.
Chloroquine-resistant Plasmodium falciparum must be assumed to be the infective agent. Once
mandatory IV therapy has been started, seek expert advice. A large multicentre randomised controlled
trial has shown mortality in severe P. falciparum malaria is lower when IV artesunate* is used rather
than IV quinine†. Artesunate should be used in preference to IV quinine only if it is immediately
available. Use:
1. artesunate (adult and child) 2.4 mg/kg IV, on admission and repeat at 12 hours and 24 hours, then
once daily until oral therapy is possible. When patient is able to tolerate oral therapy, give a full
course (6 doses) of artemether+lumefantrine, as for uncomplicated P. falciparum malaria
OR (if parenteral artesunate is not immediately available)
2. quinine dihydrochloride IV, as outlined below.
If quinine is used, an initial loading dose should be given unless the patient has received 3 or more
doses of quinine or quinidine in the previous 48 hours, or mefloquine prophylaxis in the previous
24 hours, or a mefloquine treatment dose within the previous 3 days. Frequent measurements of
blood pressure and blood glucose are required as quinine stimulates insulin secretion and can cause
hypoglycaemia. Cardiac monitoring is advised if there is pre-existing heart disease.
For loading dose, use:
1. quinine dihydrochloride (adult and child) 20 mg/kg IV over 4 hours
*Both quinine sulfate and bisulfate are available in 300 mg tablets. Quinine sulfate 600 mg is approximately equivalent
to quinine bisulfate 900 mg. Although listed as Category D, quinine has been extensively used for treating P. falciparum
malaria in pregnancy.
OR
*
Note: Dosing regimens
Where alternative drug regiments are listed, the order of preference for use of each drug is indicated by the number placed
nest to its regimen (1 for first preference, 2 for second preference and so on). Drugs of equal preference are marked with
the same number and are generally listed in alphabetical order.
14
Artesunate is an artemisinin derivative. It is not registered for use in Australia but is available via the Special Access
Scheme. Telephone (02) 6232 8111 <www.tga.gov.au/hp/sas.htm>
†
Dondorp A, Nosten F, Stepniewska K, Day N, White N for the South East Asian Quinine Artesunate Malaria
(SEAQUAMAT) group. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet
2005;366(9487):717-25. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&li
st_uids=16125588
15
2. quinine dihydrochloride (adult and child) 7 mg/kg IV over 30 minutes, followed immediately by 10
mg/kg IV over 4 hours.
For maintenance dose, use:
quinine dihydrochloride (adult and child) 10 mg/kg IV over 4 hours, 8-hourly, commencing 4 hours
after loading regimen is completed and continuing until the patient is able to begin oral treatment
(see below).
If IV quinine is required for longer than 48 hours, seek expert advice as a dose adjustment may be
necessary especially in patients with renal impairment.
To eliminate liver forms of all P. vivax infections, irrespective of where acquired, add:
primaquine 30 mg (child: 0.5 mg/kg up to 30 mg) orally, daily with food, or if nausea occurs 15 mg
(child: 0.25 mg/kg up to 15 mg) orally, 12-hourly with food. Treat for a minimum of 14 days or, in
adults more than 70 kg, until a total cumulative dose of 6 mg/kg is reached*.
To eliminate liver forms of P. ovale infections, add:
primaquine 15 mg (child: 0.25 mg/kg up to 15 mg) orally, daily with food for 14 days.
If the patient relapses after the primaquine treatment, seek expert advice.
When the patient has clinically improved, oral treatment can be commenced. Give a full course (6 doses)
of artemether+lumefantrine, as for uncomplicated P. falciparum malaria. If artemether+lumefantrine
is not available, use oral quinine combined with doxycycline or clindamycin, as for uncomplicated
P. falciparum malaria, to complete a total of 7 days of treatment with quinine.
Exclude glucose-6-phosphate dehydrogenase (G6PD) deficiency before using primaquine, as severe
haemolysis may occur in these patients. If the patient is G6PD deficient, seek expert advice.
Other forms of malaria
The development of widespread multidrug-resistant strains of Plasmodium falciparum throughout the
world, but particularly in South-East Asia, complicates recommendations for prophylaxis.
For Plasmodium vivax acquired outside Indonesia, Timor-Leste or Pacific Island Nations (including
Papua New Guinea, Solomon Islands and Vanuatu), and for Plasmodium malariae and Plasmodium
ovale, use:
chloroquine 620 mg base (= 4 tablets of chloroquine phosphate 250 mg) (child: 10 mg base/kg up
to 620 mg base) orally, initially, then 310 mg base (= 2 tablets) (child: 5 mg base/kg up to 310 mg
base) 6 hours later and on days 2 and 3, making a total adult dose of 10 tablets*.
For Plasmodium vivax acquired in Indonesia, Timor-Leste or Pacific Island Nations (including Papua
New Guinea, Solomon Islands and Vanuatu), and for less severe Plasmodium knowlesi†, use:
1. artemether+lumefantrine, as for uncomplicated Plasmodium falciparum malaria
OR
2. mefloquine 750 mg (child: 15 mg/kg up to 750 mg) orally, initially, then 500 mg (child: 10 mg/kg up
to 500 mg) 6 to 8 hours later.
Prophylaxis
There is considerable variation in the malaria prophylaxis recommendations made by different health
authorities and experts. Useful information regarding the malaria risk and the drug susceptibility profile
for specific geographical locations is available from:
••
World Health Organization. International travel and health 2010.
<www.who.int/ith/ITH2010chapter7.pdf>
••
Centers for Disease Control and Prevention. Travelers’ health—Yellow book.
<http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria-risk-information-andprophylaxis.aspx>
Alternatively, travel medicine clinics, advisory services and other experts can provide appropriate
information. This is particularly recommended for children, pregnant women, people staying in
malaria-endemic regions for more than 8 weeks, people with complex travel itineraries, and people
travelling to high-risk areas.
Mefloquine should not be used for treatment of malaria in patients who took this as prophylaxis.
For severe P. knowlesi malaria, treat as for severe malaria.
If the patient is unable to tolerate oral therapy, which is best taken with food, treat as for severe
malaria and seek expert advice.
* Primaquine failures can occur, especially when the infection has been acquired in Indonesia, Timor-Leste or Pacific
Island Nations. Evidence indicates that primaquine failure and relapse with infection are more common when primaquine
is not administered concurrently with the treatment for blood-stage infection, and/or if less than a total cumulative dose of
6 mg/kg is taken (eg only 14 days treatment in adults more than 70 kg).
* Chloroquine phosphate 250 mg is equivalent to 155 mg chloroquine base. Chloroquine is not marketed in Australia
but is available via the Special Access Scheme. Telephone (02) 6232 8111 <www.tga.gov.au/hp/sas.htm>. In adults,
hydroxychloroquine can be used as an alternative if chloroquine is not available. Use hydroxychloroquine as per the
chloroquine dosing schedule (hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base).
†
Plasmodium knowlesi has recently been recognised as an important cause of malaria in parts of South-East Asia and,
on microscopy, has the appearance of Plasmodium malariae.
16
17
Vector avoidance
Areas with chloroquine-resistant malaria
Significant protection is conferred by the simple vector avoidance measures of:
For prophylaxis in areas with chloroquine-resistant malaria (including Pacific Island Nations, SouthEast Asia, Indian subcontinent, China, Africa, South America and the Middle-East), use:
••
••
••
••
••
using effective personal insect repellent and an insecticide for indoor use;
wearing light-coloured long trousers and long-sleeved shirts in the evening;
sleeping in screened accommodation or using mosquito nets, which can be pyrethroid
impregnated;
avoiding outside activities between dusk and dawn;
avoiding perfume and aftershave.
Chemoprophylaxis
There is no drug regimen that is completely safe and effective against malaria. The decision to use
chemoprophylaxis must, therefore, be made by balancing the risk of disease against the potential
efficacy and toxicity of the drug(s) to be used. The risk of acquiring malaria depends on factors such as
the country and area visited, the time of year, the duration of visit and the type of activities undertaken.
In some places, including many major cities and tourist resorts in malaria-endemic countries, the risk
of malaria is low and no prophylaxis needs to be taken. Malaria prophylaxis should be considered
when immigrants from malarious areas who are resident in Australia return to a malarious area.
Travellers to malarious areas should be advised that chemoprophylaxis is not always effective and
any fever while away or after return needs urgent medical consultation and investigation.
As malaria can pose a serious problem for pregnant women and postsplenectomy patients, it is
strongly recommended that they do not go to malarious areas, particularly those areas with drugresistant falciparum malaria. Prophylaxis for children may also prove problematic. Doxycycline is not
recommended for children 8 years or less. Mefloquine is not approved for use in children in Australia,
but has been widely used overseas.
While the combination of chloroquine and proguanil has been widely used for malaria prophylaxis in
pregnant women and children, this regimen can no longer be relied on in most areas including Africa,
South-East Asia and the Pacific Island Nations.
1. atovaquone+proguanil tablets 250+100 mg (adult formulation)
adult and child more than 40 kg: 1 tablet orally, with fatty food or full-fat milk, daily (starting 1 to 2
days before entering, and continuing until 7 days after leaving the malarious area)
atovaquone+proguanil tablets 62.5+25 mg (paediatric formulation)
child 11 to 20 kg: 1 tablet; 21 to 30 kg: 2 tablets; 31 to 40 kg: 3 tablets orally, with fatty food or fullfat milk, daily (starting 1 to 2 days before entering, and continuing until 7 days after leaving the
malarious area)
OR
1. doxycycline 100 mg (child more than 8 years: 2.5 mg/kg up to 100 mg) orally, daily (starting 1 to 2
days before entering, and continuing until 4 weeks after leaving the malarious area)
OR
1. mefloquine 250 mg (child 5 to 9 kg: 31.25 mg [= 1/8 tablet]; 10 to 19 kg: 62.5 mg [= 1/4 tablet]; 20
to 29 kg: 125 mg [= 1/2 tablet]; 30 to 44 kg: 187.5 mg [= 3/4 tablet]) orally, once weekly (starting 2
to 3 weeks before entering, and continuing until 4 weeks after leaving the malarious area).
Doxycycline can cause oesophagitis (best avoided by taking the drug after food with plenty of fluid and
remaining upright for at least 30 minutes afterwards), photosensitivity and vaginal thrush. Mefloquine
is contraindicated in patients with neuropsychiatric disorders, epilepsy or cardiac conduction defects.
Travellers taking mefloquine as prophylaxis should be aware that there could be significant cardiotoxic
interactions if halofantrine were to be prescribed overseas subsequently for treatment of malaria.
Lumefantrine is related chemically to mefloquine and halofantrine, but no significant effects on cardiac
conduction, or an interaction with mefloquine, have been described.
Areas with mefloquine-resistant malaria
Areas with chloroquine-susceptible malaria
For prophylaxis in areas with chloroquine-susceptible malaria (now only Central America north of
Panama), use:
chloroquine 310 mg base (= 2 tablets of chloroquine phosphate 250 mg) (child: 5 mg base/kg up
to 310 mg base) orally, once weekly (starting 1 week before entering, and continuing until 4 weeks
after leaving the malarious area)*.
* Chloroquine phosphate 250 mg is equivalent to 155 mg chloroquine base. Chloroquine is not marketed in Australia
but is available via the Special Access Scheme. Telephone (02) 6232 8111 <www.tga.gov.au/hp/sas.htm>. In adults,
hydroxychloroquine can be used as an alternative if chloroquine is not available. Use hydroxychloroquine as per the
chloroquine dosing schedule (hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base).
18
For prophylaxis in areas with mefloquine-resistant malaria (including parts of South-East Asia), use
1. doxycycline or 2. atovaquone+proguanil (see ‘Areas with chloroquine-resistant malaria’ for doses).
Stand-by emergency treatment
Some authorities recommend that travellers who elect to use chloroquine for chemoprophylaxis in
areas with chloroquine-resistant malaria, or who elect to not use chemoprophylaxis, can be given
a self-treatment ‘stand-by’ course of artemether+lumefantrine or atovaquone+proguanil, for use if
medical care for a febrile illness is not likely to be available within 24 hours (see ‘Uncomplicated
Plasmodium falciparum malaria’ for doses). However, travellers should be warned that uncertain
diagnosis is a potential problem. In many tropical countries, travellers may be able to purchase,
without a prescription, treatment courses of antimalarial drugs, but should be aware of the very
common presence of counterfeit products.
19
APPENDIX 2. Malaria Surveillance Case Questionnaire
Prophylaxis / Pre-departure treatment
Prophylaxis used
Y/N
Pre-departure treatment Y / N
Drug _________________________________Date comm ___/___/___ Date comp ___/___/___
Northern Territory Malaria Surveillance Case Questionnaire
(All questions to be completed for each case or episode of disease)
Part A - CDC investigation
Surname
First name
Other names
DOB
HRN
Indigenous status
Sex
M/F
District notifying
____/____/____ Age
Missed 1 or more doses
No prescribed doses taken
Nil prescribed
Date of first treatment:
Treatment prescription
___/____/___
_____________________________________________________
If not admitted to hospital was client contacted 14 days after commencing treatment to check treatment
compliance? Y / N
Was there infection with more than one species of malaria during this episode? Y / N
Darwin / Kath / EAR / Barkly / Alice
Previous malaria diagnosed in the NT: Y / N Date: ____/____/____
Place infected
____/____/____
Outcome‡: S - Survived
DM - Died of malaria
DO - Died from another cause
True onset date
____/____/____
Malaria species
falciparum / falciparum & malariae / falciparum & vivax / malariae / ovale /
knowlesi / unspecified / vivax
‡ Outcome at discharge from hospital, or if not admitted at the time of followup
Imported case
Y/N
Hospitalised
Y/N
Admission date
____/____/____
Discharge date
____/____/____
(Please tick all species detected for
mixed infection)
Died
Y/N
Date of death
____/____/____
Malaria species
Doctor
Confirmation status Confirmed / Probable
Laboratory
Specimen date
____/____/____
Specimen type (blood)
Laboratory diagnosis method
Unknown
Was eradication treatment (primaquine) used?: Y / N No of days given: _____
Suburb/Location
Notification date
Good
Treatment
Phone
Address (Street/No)
Compliance (circle below)
Antigen detection / Microscopy / Nucleic acid testing
vivax
falciparum malariae
ovale
U - Unknown
knowlesi
Gametocytes detected (Y/N)
Location history from first fever*
Start
date
End
date
Visiting /
Resident
Street name and number
Suburb Town/ Location
Mosquito bites
(Y / N / UK)
Enhanced Data
Nationality ___________________________________ Arrival date in Australia ____/____/____
Case code (please circle):
Imported case / Relapsed case / Acquired in Australia (from an imported
case) / Acquired in Australia (not from imported case) / Induced (ie blood tx) / Unknown
No of
bites (few
or many)
Overseas travel history*
Reason for travel (please circle): Recreation / Refugee / Visiting student / Expatriate visiting relatives /
IFF / IMA / Work
Country of travel*
Region
Entry date
Departure date
*Complete all details for each location, record all places visited after dark not only residential addresses
Has this person been made aware of the possible need for entomological access to place of
residence?
Y/N
Contact phone no. for property access:_______________________
*If Indonesia, Timor or PNG indicate region
Case found by screening:
Y / N / Unknown
Interviewer
If Yes reason for screen†___________________
1. Contact tracing, 2 Co-traveller of case, 3. Illegal immigrant, 4. Migrant, 5. Other, 6. Refugee,
7. Unknown, 8. Visiting student.
Military Status (please circle)
Australian military / International military / Civilian / Unknown
_______________________ Date
Entomology notified
____/____/____
____/____/____
†
Co-travellers screened and given advice
September 2012
Y / N / No co-travellers
20
unknown
21
Time of
bites (day/
after dark)
APPENDIX 3. Use of IV artesunate for severe and complicated malaria
Part B – Medical Entomology investigation
NT residential address and other localities of potential exposure
Background
Traps set Yes � No � N/A � Vector species at residence Yes � No � N/A �
Vector report attached Yes � No � N/A �
Address
Adequately
screened
Yes/No
No. of
occupants
Distance
to nearest
breeding site
(km)
Adult record
no.
Highest potential vector
species
No/
trap/
night
Artemisinin is a sesquiterpene lactone extracted from the leaves of Artemisia annua (sweet
wormwood), used in China for treatment of fever for over a thousand years. It is a potent and
rapidly-acting blood schizontocide and is active against all Plasmodium species. It has broad activity
against asexual parasites, killing all stages from young rings to schizonts. In P. falciparum malaria,
artemisinin also kills early-stage (but not mature) gametocytes. Artesunate is a water soluble
artemisinin derivative and can be given either by intravenous or intramuscular injection. A recent
large multicentre randomised controlled trial has shown that mortality in severe P. falciparum malaria
is lower when IV artesunate is used rather than IV quinine.
Role in therapy
Traps set at nearest breeding and harbouring site Yes � No � N/A � Vectors present Yes � No � N/A �
Vector Report attached Yes � No � N/A �
••
••
••
Previous vector records in vicinity in similar months Yes � No � N/A � Report attached Yes � No � N/A �
any degree of altered consciousness, jaundice, oliguria, severe anaemia or hypoglycaemia
a parasite count above 100,000/mm3 (>2% of red blood cells parasitised)
the patient has intractable vomiting or is clinically acidotic.
Artesunate should be used in preference to IV quinine, if it is immediately available. Use artesunate
2.4 mg/kg IV bolus on admission and repeat at 12 hours and 24 hours, then once daily until oral
therapy is possible. When the patient is able to tolerate oral therapy, give a full course of artemether
+ lumefantrine 20mg/120mg – ie. six doses of four tablets (total course of 24 tablets) given over a
period of 60 hours, as for uncomplicated Plasmodium falciparum malaria.
If parenteral artesunate is not immediately available, IV quinine dihydrochloride should be used
without delay as per Therapeutic Guidelines Antibiotic 2010 14th Edition. NT hospitals hold
emergency stocks of IV quinine, even if they are also holding Artesunate stocks.
Part C: Conclusions
Patient vector contact Low � Medium � High � N/A �
Risk of infected vectors and subsequent transmission
Low � Medium � High � N/A �
Location of risk
Recommendation for fogging: Yes
Fogging conducted: Yes No N/A
Urgent IV treatment of severe malaria is essential if the patient has any of the following:
No N/A
Effective fogging practical: Yes
Recommendations / Action taken / Other comments
No N/A
Safety
Allergic reactions are rare. Many millions of patients have been treated with an artemisinin
drug, more than 10,000 of them as participants of clinical studies and at least 300 having formal
neurophysiological evaluations, without any confirmed reports of neurotoxicity.
Contraindications: Known hypersensitivity to artemisinin derivatives. In view of the reduced risk of
death of the mother, artesunate should be used in severe malaria in pregnancy, although studies on
its safety in pregnancy are still ongoing.
Presentation and cost
Artesunate is presented as artesunic acid powder 60mg (1 vial) and sodium bicarbonate 5%, 1mL
(1 ampoule). Reconstitute by adding 1mL sodium bicarbonate 5% to the artesunic acid vial (to form
sodium artesunate). The artesunate solution is then diluted in 5mL 5% dextrose (ie 10mg/mL) for
Investigating ME Officer ____________________________
Signature of ME OIC _______________________________
22
Date
/
/
23
IV bolus administration. The solution should be prepared freshly for each administration and should
not be stored. The cost of the injection is less than $4 per vial.
TGA approved indications
The Therapeutic Goods Administration (TGA) has agreed to allow hospital pharmacies to import
and hold artesunate for Category A use in patients with severe malaria under the Special Access
Scheme (SAS). Category A patients are defined in the legislation as “persons who are seriously ill
with a condition from which death is reasonably likely to occur within a matter of months, or from
which premature death is reasonably likely to occur in the absence of early treatment”.
NT Hospital Pharmacies at Royal Darwin Hospital (RDH), Katherine Hospital and Alice Springs
Hospital stock a limited supply of a batch of parenteral artesunate which has passed endotoxin and
sterility testing in an Australian TGA accredited laboratory, and which has been tested to ensure it
has a satisfactory content of artesunate. As artesunate is not registered in Australia, responsibility
for its use rests primarily with the medical practitioner and the patient. Use of artesunate requires
the approval of the on-call Infectious Diseases Physician in consultation with the on duty Intensive
Care Consultant. The treating intensive care doctor should obtain informed consent from the
patient (with documentation using a hospital consent form) and is required to forward a copy of the
Category A SAS form to the TGA within 28 days of its completion.
APPENDIX 4. Primaquine: patient information
Primaquine is given after the chloroquine or artemether/lumefatrine course is completed to eradicate
the liver forms of P. vivax or P. ovale which can lead to relapse of malaria after months or years.
The eradication course of primaquine is given daily for 14 days and should be taken with food to
prevent gastrointestinal side effects.
In case of any darkening of the urine you should stop the primaquine and contact your doctor
immediately.
Common side effects
••
abdominal pain, nausea and vomiting (when taken on an empty stomach)
••
uncommon side effects
••
haemolytic anaemia (in persons with G6PD deficiency)
••
methaemoglobinaemia
Rare side effects
Evidence
Results from randomised trials in South-East Asia and more recently Africa comparing artesunate
and quinine show clear evidence of benefit with artesunate. A randomised, controlled multi-centre
trial (SEAQUAMAT study group: Bangladesh, India, Indonesia and Myanmar) with 1431 patients
enrolled (Lancet 2005;366:717-25) found mortality of 15% (107/730) in the artesunate group which
was significantly lower than the 22% (164/731) in the quinine group; an absolute risk reduction
of 7%. Treatment with artesunate was well tolerated, whereas quinine was associated with
hypoglycaemia (RR: 3.2; 95% CI: 1.3–7.8; P = 0.009).
A second large randomised trial published in the Lancet in 2010 randomized 5425 African children
with severe malaria to receive IV artesunate or IV quinine (AQUAMAT). 230 (8•5%) patients
assigned to artesunate treatment died compared with 297 (10•9%) assigned to quinine treatment
(OR 0•75, (0•63—0•90); p=0•0022). Post-treatment hypoglycaemia was less frequent in patients
assigned to artesunate than in those assigned to quinine (48/2712 [1•8%] vs 75/2713 [2•8%]; OR
0•63, 0•43—0•91; p=0•0134). Artesunate was well tolerated, with no serious drug-related adverse
effects.
••
cardiac arrythmias
••
hypertension
••
anaemia
••
leucopenia
••
agranulocytosis
Contraindications
••
••
pregnancy
G6PD deficiency
References
1.
2.
3.
4.
World Health Organisation (WHO) Guidelines for the Treatment of Malaria 2010. Available at: http://www.
who.int/malaria/publications/atoz/9789241547925/en/index.html.
South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) group. Artesunate versus quinine for
treatment of severe falciparum malaria: a randomised trial. The Lancet 2005;366:717-25.
AQUAMAT group. Artesunate versus quinine in the treatment of severe falciparum malaria in African
children (AQUAMAT): an open-label, randomised trial. The Lancet 2010; 1647-57.
Editors, Therapeutic guidelines: antibiotic Version 14, 2010. North Melbourne: Therapeutic Guidelines Ltd.
24
25
APPENDIX 5. Guidelines for assessing unauthorised Indonesian fisherpersons for
malaria
e.
When to test fisherpersons for malaria
f.
The fisherpersons who should be tested for malaria are those who:
g.
1. Are febrile at the time of examination;
2. Give a convincing history of fever in the last 2 weeks, irrespective of whether they are febrile at the
time of examination;
3. Give a convincing history of recent treated or untreated malaria;
4. Are co-travellers of an index case of malaria. Co-travellers are fishers from the same vessel as
the index case;
5. Fishers from a different vessel that has travelled over the same route as the vessel of the index
case over the prior 3-4 weeks.
h.
What tests should be done
i.
j.
k.
l.
All fisherpersons undergoing a malaria screen should have:
1. Microscopy of thick and thin blood films; AND
2. Malaria antigen test (MAT).
Note: When co-travellers, or any other large number of fishers, are being tested for malaria, the
laboratory at RDH should be informed in advance.
Implications of a positive malaria screen for fitness to travel
Fisherpersons with P. falciparum, P. malariae and P. knowlesi malaria are NOT fit to travel and require
immediate treatment. Infections caused by P. falciparum and severe P. knowlesi can be fatal.
1. ALL cases of P. falciparum, P. malariae and P. knowlesi malaria and any malaria cases where
the species cannot be confirmed within 24 hours require assessment in hospital.
•• This is the preferred practice in the NT to prevent life threatening complications of
P. falciparum.
•• It is also important to avoid any risk of transmission of the parasite to the mosquito vectors
that are present in the Top End of the NT.
•• Asymptomatic patients with low parasitaemia eg. refugees may be treated through Hospital
in the Home (HITH) after review by the Infectious Diseases registrar or consultant at RDH.
microscopy confirmation of species by an accredited specialist microscopist;
Where the patient is gametocyte positive the first dose of artemether/lumefantrine has
been given;
The patient is affected mildly by malaria ie. tolerating oral fluids and diet and has tolerated
the first treatment dose;
The patient agrees to remain indoors in screened or air conditioned accommodation
between dusk and dawn until artemether/lumefantrine therapy is completed;
The primary health care service can be accessed by phone if the patient becomes unwell
or there is an emergency*;
The patient speaks a language for which a telephone interpreter or friend/family member
can interpret eg. Swahili, French, Dinka, Arabic, Kirundi. If it is a rare language and no
lingua franca can be found, the patient will have to be admitted;
Adequate follow up arrangements are able to be arranged;
The patient is notified to CDC so that CDC officers can ascertain that patients treated
as HITH/outpatients do not pose a public health risk. A phone message may be left with
CDC after hours; and
The case has been discussed with an Infectious Diseases (ID) Physician at RDH
(available 24 hours per day) to check:
•• The above points a to l
•• Clinical condition
•• Follow-up arrangements
•• Spleen size and offer advice about activity restrictions.
If ALL of the above criteria are met, these fisherpersons can be given treatment on an outpatient
basis through HITH/or supervised by the primary health care service and be certified fit to be
repatriated on completion of primary treatment for malaria.
*Please note: There is a HITH nurse on call 24hours, but she only speaks English.
Unless the patient speaks English, there should be another contact person (Melaleuca Refugee Centre or friend/
neighbour) who is available to immediately attend the house if called.
For all malaria cases
1. Treatment and follow up should be instituted in accordance with the Malaria Guidelines for Health
Professionals in the Northern Territory (2012).
CONTACT
CDC Darwin 8922 8804
2. Fisherpersons with confirmed P. vivax, or P. ovale can be treated by HITH or supervised by
their primary health care service while in immigration detention provided:
a. Parasitaemia is <1%;
b. There are no significant co-morbidities eg. ischaemic heart disease;
c. Pregnancy is excluded:
d. There is no evidence of co-infection with P. falciparum malaria. This requires blood
26
27
APPENDIX 6. Advise to parents of students arriving in the NT from malaria endemic
areas
threatening. Malaria can kill by infecting and destroying red blood cells (anaemia) and by clogging
the blood vessels to the brain (cerebral malaria) or vital organs.
Postal Address: PO Box 40596
Casuarina NT 0811
Tel: 89228804
Fax: 89228310
Advice to parents of students arriving in the NT from malaria
endemic areas
What is Malaria?
Malaria is a parasitic disease transmitted by Anopheles mosquitoes. There are 4 types of
parasites that cause malaria: Plasmodium ovale, P. malariae, P. knowlesi, P. vivax, and
P. falciparum. The last 2 are the most common.
Primarily, malaria is an infection of the red blood cells, but other parts of the body may be
affected. Malaria caused by P. falciparum and severe P. knowlesi is life threatening and can
cause multiple organ damage, coma and death.
How is it spread?
Malaria is spread by Anopheles mosquitoes. The parasite enters the body in mosquito saliva
when a person is bitten by an infected Anopheles mosquito. The parasite first infects the liver
where it begins to multiply. After some days, the resulting parasites are released into the blood
stream to infect the red blood cells, where they continue to multiply, eventually bursting the red
blood cells and further infecting others. If they reach high numbers they may then clog up blood
vessels and cause organ damage and severe disease. Some of the parasites in the red blood
cells develop into the sexual stages (gametocytes). If these stages are ingested when a mosquito
bites an infected person, they develop in the gut of the mosquito for 10 –14 days, and then enter
the salivary glands, ready to infect a person at the next bite.
Prolonged untreated malaria infection can also cause the spleen to enlarge (splenomegaly).
Splenomegaly can be a problem if your child is playing sport or suffers an abdominal injury, as the
spleen can rupture requiring emergency surgery. Splenic rupture can sometimes be fatal.
Why does malaria relapse?
Some forms of malaria such as P. vivax and P. ovale exist as dormant forms that remain in the
liver for months or years before producing the disease.
With other forms such as P. falciparum and P. malariae (and in some cases P. vivax), the disease
can reoccur after apparent recovery, due to either inadequate treatment or infection with a drug
resistant strain.
How is it diagnosed?
Malaria is diagnosed by a blood test. The blood is examined down a microscope looking for
malaria parasites inside the red blood cells. An antigen test is done at the same time, which can
indicate that your child has been exposed to malaria but has no visible parasites.
What is the treatment?
All cases of P. falciparum malaria in the NT are admitted to hospital because it can rapidly
become life threatening. Cases of malaria other than P. falciparum can sometimes be treated at
school if the patient agrees to stay indoors between dusk and dawn. This is to avoid any risk of
transmission of the parasite to the local Anopheles mosquitoes.
Treatment must be given in consultation with specialist physicians.
What should be done for children coming from areas with malaria?

Soon after your child arrives in the NT, the school will offer a malaria symptom review and a
malaria blood test. This blood test will look for the malaria parasite in the blood and test for
malaria antigen. If either test is positive, then your child will be seen at the hospital by the
infectious diseases team and receive malaria treatment.

The last case of locally acquired malaria in the Northern Territory was in 1962 and Australia was
declared free of malaria by the World Health Organisation (WHO) in 1981. However, a number of
species of Anopheles mosquitoes exist in the NT and the malaria parasite could be re-introduced
into local mosquitoes if infected people are bitten. Transmission to mosquitoes could occur
anywhere in the Top End, down to latitude of 19 degrees, which is just north of Tennant Creek.


ABN: 84 085 734 992
Screening on each return from holiday or visit from malaria area
Every time your child returns from holidays malaria screening will need to occur. In some
cases you may choose for your child to receive malaria preventive treatment for when they go
home for the holidays. In this case, please let the school nurse know and she will organise an
appointment with a general practitioner for medical review and prescription of medication. It is
important that the child takes the medication according to instructions, including after return to
Australia. They will be asked their medication compliance on return. If there is any doubt on
their compliance, then they will require a blood test.
Symptoms appear about 9-14 days after a malaria-infected mosquito bite, and coincide with the
rupture of the red blood cells. Symptoms are often delayed in people who have lived in malarious
areas and who may have developed some immunity.
the third or fourth day. Untreated, infection can progress rapidly and become life
Early presentation to school nurse for fever or feeling unwell at any time
Occasionally the screening tests are negative even when malaria parasites are present or are
in low numbers and so in the future your child is advised to go and see the school nurse if
they develop a fever or become unwell.
What are the symptoms?
Typically malaria produces fever, rigors (shakes), sweating, headache, vomiting and other flu-like
symptoms. Sometimes there is a 2 or 3 day period of reduced symptoms before a recurrence on
Spleen check
When coming from an area with malaria a child’s spleen can be enlarged even if active
malaria is not found on screening and this is very important to recognise before engaging in,
for instance, sport.
Where is it found?
Malaria is found throughout the tropical and subtropical regions of the world. Areas of high
transmission are found predominantly in rural areas in South America (e.g. Brazil), south-east
Asia (e.g. Thailand, Indonesia and East Timor), Western Pacific (Papua New Guinea, Solomon
Islands and Vanuatu) and throughout sub-Saharan Africa.
Arrival screening for malaria
30 August 2012
Page 2 of 3
Department of Health is a Smoke Free Workplace
28
29
www.nt.gov.au
APPENDIX 7. Medical Entomology investigation
More detailed information is available from the Medical Entomology (ME) document Entomological
Investigation around Malaria Cases, 2011.
CONSENT
Screening will occur at St Johns College after semester break when your child has returned from
holiday or visiting from a malaria area.
I_______________________ give consent for ________________________ to have a malaria
symptom review and a malaria blood test (valid for the next 12 months).
Child’s date of birth
/
/
Address_____________________________
Signature____________________________
Date
/
/
If your child needs any treatment the Health staff will ask your permission before carrying out any
further evaluation of treatment.
You will be notified of the results of the screening.
For any further queries please contact Centre for Disease Control School Malaria Program
Coordinator
(08) 8922 8804
30 August 2012
Page 3 of 3
30
1. Assess epidemiological data provided in CDC questionnaire, if no gametocytes present no
action required.
2. Assess whether routine trap information is sufficient, or extra traps will need to be set,
considering location, peak vector abundance periods and prevailing environmental conditions.
Using the ME database, assess the actual or potential level of vector activity around case
locations from most recent results
Include:
•• Last 5 years data for similar months
•• Search for An. farauti, An. bancroftii, An. hilli, An. annulipes, An. amictus
•• Assess results and further action
If there is low potential vector presence with no extra adult trapping required based on location,
peak periods and prevailing environmental conditions, no further action is required.
3. If there is a potential for vectors present, assess the nearest breeding and resting sites at the
case house and within 1 km using CO2 baited encephalitis vector survey (EVS) traps.
4. Triggers for ME action based on current entomological information:
•• >2 An. farauti at residence or, >10 of all other Anopheles sp. at residence; initiate fogging.
•• or >10 An. farauti or, >40 other Anopheles sp. at breeding harbouring sites within 1 km;
assess further by setting more traps and assess new results, or initiate fog.
•• If current Anopheles sp. abundance is less than the trigger levels, further assessment
should consider peak abundance periods and prevailing environmental conditions, which
may necessitate extra trapping.
5. If precautionary fogging is to be carried out, inform the Director CDC and Chief Health Officer
(CHO) by email and phone. Fogging is usually in nearest mosquito breeding or harbourage
area outside residential areas. If fogging is needed in residential areas, approval is required
from the CHO. Use non residual insecticides eg. bioresmethrin or similar in residential areas,
and malathion for non-residential areas.
6. If trapping or fogging is required, complete the ME form ‘Investigation around a proven malaria
case - Medical Entomology - DoH’. A case reference is used in all documentation.
7. If ME undertakes any action: email malaria form and relevant information eg; trap results,
fogging route, to the CDC Malaria Surveillance Officer (or fax 28310) and phone to confirm
receipt.
8. All details of the case including fogging responses are filed in the ME database.
www.nt.gov.au
31
APPENDIX 8. Malaria factsheet
CENTRE FOR DISEASE CONTROL
Malaria
December 2012
What is Malaria?
Malaria is a parasitic disease transmitted by
Anopheles mosquitoes. There are 5 types of
parasites that cause malaria: Plasmodium
ovale, P. malariae, P. knowlesi, P. vivax, and
P. falciparum. The last 2 are the most common.
Primarily, malaria is an infection of the red
blood cells, causing recurring fever of sudden
onset. Malaria caused by P. falciparum is life
threatening and can cause multiple organ
damage, coma and death.
How is it spread?
Malaria is spread by female Anopheles
mosquitoes. The parasite enters the body in
mosquito saliva when a person is bitten by an
infected mosquito. The parasite first infects the
liver where it begins to multiply. After some
days, the resulting parasites are released into
the blood stream to infect the red blood cells,
where they continue to multiply, eventually
bursting the red blood cells and further
infecting others. If they reach high numbers
they may cause severe disease or even death.
Some of the parasites in the red blood cells
develop into the sexual stages (gametocytes).
If these stages are ingested when a mosquito
bites an infected person, they develop in the
gut of the mosquito for 10 –14 days, and then
enter the salivary glands, ready for the next
bite.
Where is it found?
Malaria is found throughout the tropical and
subtropical regions of the world. Areas of high
transmission are found predominantly in rural
areas in South America (e.g. Brazil), southeast Asia (e.g. Thailand, Indonesia and East
Timor), Western Pacific (Papua New Guinea,
Solomon Islands and Vanuatu) and throughout
sub-Saharan Africa.
The last case of locally acquired malaria in the
Northern Territory was in 1962 and Australia
was declared free of malaria by the World
Health Organisation (WHO) in 1981. However,
a number of species of Anopheles mosquitoes
exist in the NT and the malaria parasite could
be re-introduced into local mosquitoes if
infected travellers from overseas are bitten
here. The disease could become established
anywhere in the Top End, down to a latitude
of 19 degrees which is just north of Tennant
Creek.
What are the symptoms?
Symptoms appear about 9-14 days after a bite
from an infected mosquito, and coincide with
the rupture of the red blood cells. Symptoms
are often delayed in people who have lived in
malarious areas and who may have developed
some immunity.
Typically malaria produces fever, rigors
(shakes), sweating, headache, vomiting and
other flu-like symptoms. Sometimes there
is a 2 or 3 day period of reduced symptoms
before a recurrence on the third or fourth day.
Untreated, infection can progress rapidly and
become life threatening. Malaria can kill by
destruction of red blood cells (anaemia) and by
altering the function of vital organs such as the
brain, (cerebral malaria) lungs or kidneys.
Why does malaria relapse?
P. vivax and P. ovale exist as dormant forms
that remain in the liver for months or years
before producing the disease.
With P. falciparum, the disease can reoccur
after apparent recovery, due to either
inadequate treatment or infection with a drug
resistant strain. P. malariae can rarely persist
with very low levels of parasite in the peripheral
blood for decades.
P. knowlesi produces acute illness but does
not cause relapse.
How is it diagnosed?
Malaria is diagnosed by a blood test. The blood is
examined under a microscope looking for malaria
parasites inside the red blood cells. All travellers
from malarious areas who become ill or develop a
fever should be tested.
What is the treatment?
All cases of P. falciparum malaria in the NT are
admitted to hospital because this form of malaria
can rapidly become life threatening. Cases of
malaria other than P. falciparum can sometimes
be treated at home if the house is adequately
screened and if the patient agrees to stay indoors
between dusk and dawn. This is to avoid any risk of
transmission of the parasite to the local Anopheles
mosquitoes.
Treatment must be given in consultation with
specialist physicians.
Before travelling overseas
Check whether the countries to which you are
travelling are affected by malaria by contacting your
GP, Travel Health Clinic or referring to the internet:
WHO International Travel and Health website:
http://www.who.int/ith/en/
Or the Centers for Disease Control and Prevention:
http://wwwnc.cdc.gov/travel/
If you are travelling to an affected country you
will often need preventative medication. Contact
your GP or Travel Clinic to organise anti-malarial
medication for your trip. Some medication must be
started 1 week prior to entry to the affected area.
How to protect yourself from
mosquito bites
While in affected areas there are measures which
should be taken to reduce the risk of mosquito
bites.
• Avoid being outdoors between dusk and dawn
to avoid mosquito bites, particularly in poorly
lit areas, rural areas, or the outskirts of large
towns.
• If accommodation is not well screened, sleep
inside mosquito netting. Use insecticide treated
bed nets and clothing in high risk areas.
If you return from a malarious area
and develop symptoms
If you develop symptoms of malaria within 2 years of
visiting a malarious area contact your GP or hospital
emergency department immediately for an urgent
medical assessment. Remember to inform the
medical officer of where you have travelled as this
will help determine your risk of malaria and the type
of treatment required.
If you have malaria, the people you have travelled
with (particularly to high risk areas such as Africa,
PNG, East Timor and parts of Indonesia including
Flores, Lombok and surrounding islands) should also
be tested.
For more information contact your nearest
Centre for Disease Control.
Darwin
8922 8044
Katherine
8973 9049
Alice Springs
8951 7540
Tennant Creek
8962 4259
Nhulunbuy
8987 0357
For more information on mosquitoes and virus
ecology contact Centre for Disease Control,
Medical Entomology on 8922 8901.
Further fact sheets and protocols are available at:
www.nt.gov.au/health/cdc
Malaria
Malaria
32
• Avoid scents on the body, e.g. perfume,
deodorants, and sweat, since these can attract
mosquitoes.
• Use protective clothing in outdoor situations
including covering feet, legs and arms. Loose,
light coloured clothing is best.
• Use personal repellents containing DEET or
picaridin on areas of exposed skin in combination
with protective clothing.
• Use electric insecticide devices using repellent
treated pads in indoor or enclosed areas.
• Use mosquito coils, or candle heated or gas
operated devices using insecticide treated pads
for patio and veranda or relatively sheltered or low
wind outdoor situations.
For more information on protection measures see
Personal protection from mosquitoes.
33
APPENDIX 9. Malaria factsheet (Indonesian)
Apakah Malaria?
Malaria adalah penyakit yang disebabkan oleh
parasit yand ditularkan oleh nyamuk Anopheles.
Ada 5 jenis parasit yang dapat menyebabkan
malaria: Plasmodium ovale, P. malariae, P.
vivax, P.knowlesi dan P. falciparum. Dua jenis
terakhir adalah yang paling sering ditemukan.
Pada dasarnya, malaria adalah infeksi pada
sel-sel darah merah, yang menyebabkan
demam berulang dengan tiba-tiba. Malaria
yang disebabkan oleh P. falciparum sangat
berbahaya dan dapat menyebabkan kerusakan
berbagai organ tubuh, koma dan kematian.
Bagaimana malaria menyebar?
Malaria disebarkan oleh nyamuk Anopheles
betina. Parasit masuk ke tubuh melalui ludah
nyamuk pada saat seseorang digigit oleh
nyamuk yang terinfeksi. Parasit ini mula-mula
menyebabkan radang pada liver dimana ia
berbiak. Setelah beberapa hari, parasit-parasit
yang terbiak dilepas ke saluran darah untuk
menjangkiti sel-sel darah merah, dimana
mereka terus berbiak, sampai sel-sel darah
merah menjadi pecah dan mengakibatkan
infeksi pada sel-sel lainnya. Jika jumlahnya
menjadi sangat besar, hal ini dapat
menimbulkan sakit parah atau bahkan kematian.
Sebagian dari parasit dalam sel-sel darah
merah berkembang memasuki tahap jantan dan
betina (gametosit). Jika pada tahap ini seekor
nyamuk mengigit orang yang terinfeksi, parasit
akan berkembang dalam perut nyamuk selama
10-14 hari, lalu masuk ke kelenjar ludah, siap
untuk dijangkitkan pada saat nyamuk menggigit
seseorang.
Dimana penyakit ini menyebar?
Malaria ditemukan diseluruh wilayah tropis
dan subtropis di dunia. Daerah-daerah dimana
terjadi banyak penularan adalah wilayah
perkampungan di Amerika Selatan (misalnya
Brazil), Asia Tenggara (misalnya Thailand,
Indonesia dan Timor Timur), Pasifik Barat
(Papua Nugini, Kepulauan Solomon dan
Vanuatu) serta sub-Sahara di Afrika.
Di Northern Territory, kasus malaria yang
terjangkit secara lokal terakhir terjadi pada
tahun 1962 dan Australia dinyatakan bebas dari
Malaria oleh World Health Organisation (WHO)
pada tahun 1981. Namun, beberapa spesies
nyamuk Anopheles masih ada di NT dan parasit
malaria dapat menjangkiti nyamuk setempat bila
ada pendatang yang terinfeksi dari luar negeri
digigit oleh nyamuk setempat. Penyakit ini dapat
berjangkit di wilayah utara NT, sampai dengan
lintang 19 derajat, sedikit di utara Tennant
Creek.
Apakah gejala-gejalanya?
Gejala-gejala muncul sekitar 9-14 hari setelah
digigit oleh nyamuk yang terinfeksi, dan
bersamaan dengan pecahnya sel-sel pembuluh
darah merah. Pada orang yang tinggal di daerah
yang banyak terjangkit malaria, gejala-gejalanya
mungkin muncul lebih lambat karena orang
tersebut mungkin memiliki sedikit kekebalan.
Pada umumnya malaria mengakibatkan demam,
menggigil, keringatan, sakit kepala, muntahmuntah dan gejala serupa flu lainnya. Kadangkadang gejala-gejala ini berkurang selama 2-3
hari namun muncul kembali pada hari ketiga
atau keempat. Tanpa pengobatan, infeksi dapat
berkembang dengan cepat dan membahayakan
jiwa. Malaria dapat mengakibatkan kematian
melalui penghancuran sel-sel darah merah
(anaemia) dan melalui perubahan pada fungsi
organ tubuh yang penting seperti otak (cerebral
malaria), paru-paru dan ginjal.
Mengapa malaria dapat kambuh?
P. vivax dan P. ovale tinggal dalam bentuk
tidak aktif pada liver selama berbulan-bulan
atau bertahun-tahun sebelum menyebabkan
munculnya penyakit. Pada P. falciparum,
penyakit dapat kambuh kembali setelah
seseorang terlihat sembuh, karena pengobatan
yang kurang memadai atau orang tersebut
tertular jenis yang kebal terhadap obat. P.
malariae jarang dapat bertahan dengan tingkat
parasit rendah pada darah selama puluhan
tahun.
34
Bagaimana di-diagnosa ?
Malaria di-diagnosa melalui tes darah. Darah
diperiksa dibawah mikroskop untuk dilihat
apakah terdapat parasit malaria dalam sel-sel
darah merah. Semua orang yang bepergian ke
daerah dimana malaria berjangkit dan jatuh sakit
atau mengalami demam harus diperiksa.
Bagaimana mengobatinya?
Seluruh kasus malaria P. falciparum di NT
dikirim ke rumah sakit karena malaria jenis ini
dapat membahayakan jiwa dalam waktu singkat.
Kasus-kasus diluar P. falciparum kadangkala
dapat diobati di rumah jika rumah tersebut
dilindungi kawat nyamuk dan jika pasien setuju
untuk tinggal dalam rumah dari senja hingga
fajar. Hal ini untuk menghindari resiko penularan
parasit ke nyamuk Anopheles setempat.
Pengobatan harus dilakukan dengan
berkonsultasi pada dokter spesialis. Sebelum
bepergian ke luar negri, periksalah apakah
negara-negara yang akan Anda kunjungi
terjangkit malaria dengan menghubungi dokter
Anda, Travel Health Clinic atau melalui internet:
Situs web WHO International Travel and Health
http://www.who.int/ith/index.html
atau Centers for Disease Control and Prevention
(Pusat Pengendalian dan Pencegahan Penyakit)
http://www.cdc.gov/travel/diseases.htm#malaria
Jika Anda akan bepergian ke negara yang
terjangkit, pada umumnya Anda memerlukan
obat pencegahan. Hubungi dokter Anda atau
Travel Clinic untuk memperoleh obat antimalaria bagi perjalanan Anda. Obat-obat tertentu
perlu diminum 1 minggu sebelum memasuki
wilayah yang terjangkit.
Bagaimana melindungi diri Anda dari gigitan
nyamuk
Selama di daerah yang terjangkit, ada hal-hal
yang dapat dilakukan untuk mengurangi resiko
digigit nyamuk.
•• hindari berada di luar bangunan antara senja
dan fajar, terutama di daerah yang kurang
penerangannya, daerah perkampungan, atau
pinggiran kota besar
•• tutupi badan Anda (terutama lengan, tungkai
kaki dan telapak kaki) antara senja dan fajar
35
••
••
••
••
pakaian yang longgar dan berwarna terang
adalah yang terbaik
gunakan penolak serangga pada kulit yang
tidak terlindungi pada jam-jam yang beresiko
tinggi; pilih penolak yang mengandung DEET
atau picaradin
hindari bau-bauan pada tubuh, misalnya
parfum, deodoran, dan keringat, karena dapat
menarik nyamuk
jika akomodasi tidak terlindung dengan
baik, tidur dengan menggunakan kelambu.
Gunakan kelambu dan pakaian yang telah
disemprot penolak serangga di daerah
beresiko tinggi
gunakan obat nyamuk bakar atau pembasmi
serangga dalam bentuk uap di ruang tertutup
Jika Anda kembali dari daerah yang
terjangkit malaria dan menunjukkan gejalagejala malaria
Jika Anda menunjukkan gejala-gejala malaria
dalam 2 tahun setelah mengunjungi daerah
yang terjangkit malaria, hubungi dokter atau
bagian gawat darurat rumah sakit dengan
segera untuk pemeriksaan medis. Jangan lupa
memberi tahu petugas kesehatan tempat-tempat
yang Anda kunjungi karena ini akan membantu
menentukan tingkat resiko Anda terkena malaria
dan jenis perawatan yang diperlukan.
Jika Anda terkena malaria, orang-orang yang
bepergian bersama Anda (terutama ke daerah
beresiko tinggi seperti Afrika, PNG, Timor Timur
dan bagian dari Indonesia termasuk Flores,
Lombok dan kepulauan sekitarnya) perlu juga
diperiksa.
Untuk informasi lebih lanjut hubungi cabang
CDC atau bagian Entomology Medis
terdekat.
Entomology Medis
CDC Darwin CDC Katherine CDC Nhulunbuy CDC Tennant Creek CDC Alice Springs 89228548
89228044
89739049
89870357
89624259
89517549
Lembaran informasi selanjutnya dan protokol
perawatan tersedia di
http://www.nt.gov.au/health/cdc
July 2011
Northern Territory Guidelines for
Malaria
Northern Territory Department of Health
www.nt.gov.au/health/cdc/cdc.shtml

Guidelines for Malaria

Transcription

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